06050236 CITY OF CUPERTINO
BUILDING DIVISION PERMITS ZMI .
BUILDING ADDRESS: ANN JEFFERSON PERMIT NO'06050236
10791 NORTHFORDE DE
OWNER'S NAME: PERMIT ISSUE DATE
ANN JEFFERSON 05'126.12006
SANITARY NO. CONTROL NO.
E:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
i p p LICENSED CONTRACTOR'S DECLARATION Job Description
U 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
with Section 7000)of Division 3 of the Business and Professions Code.and my license is
Z< in full force and effect. REPLACE 3 SLIDING GLASS WINDOWS AND 4 BEDROOM
)M z License Class Lic.# WINDOWS
p Date Contractor
ARCHITECTS DECLARATION WINDOW MAX NEEDS TO PURCHASE A BL
Z x 1 understand my plans shall be used as public records
5WU
U.
in Licensed Professional
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
L p C following reason.(Section 7031.5,Business and Professions Code:Any city or county
m which requires a permit to construct,alter,improve,demolish,or repair any structure
Z y prior m its issuance,also requires the applicant for such permit to file a signed statement Valuation
< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area
(commencing with Section 7000)of Division 3 of the Business and Professions Code)or $4600
i that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars($500).
❑1,as owner of the property,or my employees with wages as their sole compensation,
will do the work and the structure is not intended or offered for sale(Sec.704t,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an oder of-
property who builds or improves thereon,and who does such work himself or=his ;,;
own employees,provided that such improvements are not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion,thowner-_
builder will have the burden of proving that he did not build or improve for p of
sale.). I
U.".owner of the property,am exclusively contracting with licensed con to
construct the project(Sec.7044,Business and Professions Code:)The Coatracsoes U- ?,
cense Law does not apply to an owner of property who builds or improves thereon,an
who contracts for such projects with a conu=or(s)licensed pursuant to the Contractor's
License Law.
❑1 am exempt under See B&P C for this reason
Owner a
WORKERATIONDECLARA1f0
I hereby affirm under penalty ollpeoury one of the following declarations:
U I have and will maintain a Certificate of Consent to self-insure for Worker's Compcn-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑I have and will maintain Workces Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number arc:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued,I shall not
employ any person in any mamnor sou become sub' to the Workers'Compensation
Laws of Califo Date a
Applicant
NOTICE TO APPLICANT:If,after g cdificate of Exemption,you should
become subject to the Worker's ComptaUd visions of the Labor Code,you must
,J O forthwith comply with such provisions or this permit shall be deemed revoked.
Z" CONSTRUCTION LENDING AGENCY
Fr rte. I hereby affirm that there is a construction lending agency for the performance of
fYr> the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lendces Name
Lcndees Address
U 0 1 certify that I have read this application and state that the above information is
V.O- correct.l agree to comply with all city and county ordinances and state laws relating to
Q Ubuilding construction,and hereby authorize representatives of this city to enter upon the
U above-mentioned properly for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
rA liabilities,judgments,costs and expenses which may in any way steric against said City
rJ Z in consequence of the granting of this permit. Date
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOUR EGULATiO
` e-roofs
Signature of Applicant/Contractor are Type of Roof
HAZARDOv1A S DISCLOSURE
Will the applicant or futtill' g upanL store or handle hazardous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? `/ All roofs shall be inspected prior to any roofing material being installed.
t7y�
❑Yes
Will the applicant or future building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
..nit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and]5534.1 understand that if the building
does not currently have a 1cpau6 that it is my responsibility to notify the occupant of the
re menswhic m me 'or to of a Certificate of Occupancy, Signature of Applicant Date
r. All roof coverings to be Class"B"or better
Owner or authorized agent Date